COVID‐19 (Omicron strain) hospital admissions from a virtual ward – who required further care?

Abstract Background The COVID‐19 virtual ward was created to provide care for people at home with COVID‐19. Given this was a new model of care, little was known about the clinical characteristics and outcomes of patients requiring admission to hospital from the virtual ward platform. The aims were to characterise hospital admission volume, patient epidemiology, clinical characteristics, and outcome from a virtual ward in the setting of an Omicron (BA.1, BA.2) outbreak. Methods A retrospective observational study was performed for all virtual ward patients admitted from 1st January 2022 to 25th March 2022 (over 16 years old). Epidemiological, clinical and laboratory data was reviewed on all patients who required hospital admission. Results A total of 7021 patients were cared for on the virtual ward over the study period with 473 referred to hospital for assessment. Twenty‐six (0.4%) patients were admitted to hospital during their care on the ward. Twenty‐two (84.6%) admissions were COVID‐19 related. Fifty three percent of the hospitalised patients were fully vaccinated and 11 had received prior therapeutics for COVID‐19. Shortness of breath was the most common reason for escalation to hospital. Chest pain was the second most common reason and the most common diagnosis after investigation was non‐cardiac chest pain. Conclusions Few patients required admission from the virtual ward in the setting of the Omicron variant (BA.1, BA.2) as a direct result of COVID‐19 disease and virtual ward care. Shortness of breath and chest pain were the most common symptoms driving further clinical care.


| INTRODUCTION
The Metro North COVID-19 Virtual Ward was created to provide care for people at home with COVID-19 in South-East Queensland, Central West and Norfolk Island. This covers a population approaching 900 000 and 4157 km 2 . Within these catchments there are 22 public hospitals including 1 quaternary, 1 tertiary and 2 secondary hospitals. The virtual ward structure has been previously described by McCarthy et al. (2022) and had a constant evolution in response to changing needs of COVID-19 management and demand. 1 Like a traditional hospital ward, the virtual ward had a list of inpatients and was managed by a multidisciplinary team. However, unlike a traditional hospital ward, the virtual ward patients were at home and consultations were provided over the phone or using telehealth.
Illness severity was characterised by the Australian guidelines for the clinical care of people with COVID-19 into mild, moderate, severe and critical illness. 2 The Virtual Ward predominantly managed mild cases of COVID-19. However, occasionally moderate to severe cases would be identified on review and these cases would be referred for in person assessment and management as required.
To provide care the virtual ward needed to be able to recognise and escalate moderate-severe COVID-19 cases, complications of COVID-19 and other medical conditions requiring hospital level care and assessment. In a large multinational observational study, fever, cough, and shortness of breath were the most common symptoms in hospitalised patients for COVID-19. 3 Atypical symptoms included nausea, vomiting and abdominal pain for people less than 60 and confusion was the most common atypical symptom for those over 60. 3

| Virtual Ward and Escalation Process
Patients were admitted to the COVID-19 Virtual Ward while in isolation at their home. The Virtual ward included administration, nursing, pharmacy, medical and social work staff. An escalation hotline was available to patients after hours.
In this initial consultation patients were risk stratified based on risk of possible disease progression. All patients received daily phone calls and symptoms were assessed with standardised escalation criteria. Higher risk patients received a pulse oximeter. Additional questions were asked for pregnant patients that screened for any issues with pregnancy. The above system allowed escalation of patients to a Medical Officer for review and then to the emergency department if required. Transport to the nearest emergency department was arranged via an ambulance and the Senior Medical Officer of that department was made aware of the patients expected arrival.
Antiemetics, analgesia, antibiotics and oral antiviral therapies when they became available could be delivered to the patient's home and were prescribed according to the Australian National Guidelines. 2 Sotrovimab and then EVUSHED (tixagevimab and cilgavimab) at a later point were normally given in the outpatient setting but for some time required hospital presentation until this facility was set up. Key changes in ward strategy are listed in Table 1.
Patients were discharged from the virtual ward after 7 days if they met the national guideline criteria relating to symptom T A B L E 1 Key changes in the virtual ward.

Month
Key changes implemented

| Data Analysis
The data was analysed using SPSS Statistics 27. Descriptive statistics were expressed as a number (%) and mean or median for continuous variables.   Table 5.

| Admission Characteristics and Outcomes
The summary of the admission data is shown in Table 6.
There were no instances of cardiac chest pain or pulmonary embolus substantiated by relevant imaging/pathology results. One patient was admitted for an asthma exacerbation and tested negative for COVID-19, having already completed the 7-day isolation period and therefore was classed as an unrelated admission. Admissions not directly related to COVID-19 included antepartum haemorrhage (n = 1), Epstein Barr Virus infection (n = 1) and urinary tract infection (n = 1). Fully vaccinated, n (%) 3 (11.5) T A B L E 4 Escalation characteristics (in patients admitted to hospital) (n = 26).
T A B L E 5 Chest pain diagnoses of patients admitted to hospital (n = 10).

Chest pain diagnoses Number of patients (%)
Community acquired pneumonia 2 Lower respiratory tract infection 2

Asthma exacerbation 2
Non-cardiac chest pain, spontaneously resolved 3 Atelectasis 1 also a decreased in presentations of Chronic Obstructive Pulmonary Disease exacerbations due to physical and behavioural measures taken to limit COVID-19 transmission. 13 Fifty three percent of the patients admitted to hospital from the virtual ward were fully vaccinated. This is significantly lower than the population vaccination rate at this time which was gradually increasing and by 20 March 2022 was greater than 80% of the community population. 14 Almost 60% of the cohort were not able to receive therapeutics due to their unavailability or less commonly patent refusal.
Thus, therapeutics did not pay a major role in prevention of hospital admission.

Shortness of breath was the most common reason for a Medical
Officer to escalate a patient for in-hospital assessment, despite the availability of pulse oximeters. As this was a new unvalidated process at this time clinician discretion was utilised as to whether the readings changed patient care and if a patient was kept at home when experiencing this symptom with normal oximetry. In-hospital mortality for this group was 3.8% (n = 1) and ICU admissions was 3.8% (n = 1). This is largely different to the epidemiology and clinical characteristics of COVID-19 in Wuhan in 2019 with the alpha variant where there were 138 hospitalised patients with COVID-19 pneumonia, with 26% needing ICU treatment and a mortality of 4.3%. 15 Previous studies have shown that the delta outbreak in unvaccinated population would lead to a greater burden on the health care system. 16 This study has shown that the burden on the hospital system was very low with the implementation of the virtual ward.
Study limitations included that, in the latter half of the study, the model of care was an "opt in" one and thus patients admitted to the virtual ward were self-selected. The change in patients' management that occurs with greater familiarity with disease manifestations of a new variant and greater familiarity with technology as it is introduced such as pulse oximetry. Also, availability of therapeutics increased in the latter half of the study period.

| CONCLUSIONS
From the virtual ward setting hospital presentations to the emergency department and for admission was a small percentage of the cohort.
This was in the setting of a vaccination rate of 57%, limited therapeutics for most of the study period and when Omicron (BA.1/BA.2) was the predominant strain. Shortness of breath and chest pain were the most common symptoms resulting in hospital admission.

DECLARATIONS
No funding was received for this study.
Declarations of interest: none.
All relevant ethical guidelines have been followed. There was no material reproduced from other sources. This study was not registered on a clinical trials registry.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

PEER REVIEW
The peer review history for this article is available at https://publons. com/publon/10.1111/irv.13108.